Chung Eun Ja, Choi Eun Young, Myung Heejae
Nursing Department, Seoul National University Bundang Hospital, Seoul, Korea.
Stud Health Technol Inform. 2006;122:982.
The ENR System of Seoul National University Bundang Hospital was made after analyzing paper-based narrative nursing records with ICNP, a combinatorial nursing terminology. In this study, we analyzed paper-based narrative nursing records with ICNP on surgical patients and evaluated practical use of the terminology and the system after building and applying ENR System. We found that we need to add new concepts to the ICNP to improve expression of nursing records especially in describing nursing actions.
首尔国立大学盆唐医院的电子护理记录（ENR）系统是在使用国际护理实践分类法（ICNP，一种组合式护理术语）对纸质叙述性护理记录进行分析之后创建的。在本研究中，我们使用ICNP对手术患者的纸质叙述性护理记录进行了分析，并在构建和应用ENR系统后评估了该术语和系统的实际使用情况。我们发现，需要向ICNP中添加新的概念，以改善护理记录的表达，尤其是在描述护理行动方面。
